1508080532 NPI number — STONE CREEK DENTAL, P.A.

Table of content: (NPI 1508080532)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508080532 NPI number — STONE CREEK DENTAL, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STONE CREEK DENTAL, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508080532
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7935 STONE CREEK DR
Provider Second Line Business Mailing Address:
STE. 150
Provider Business Mailing Address City Name:
CHANHASSEN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55317-4610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-937-2839
Provider Business Mailing Address Fax Number:
952-401-3307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7935 STONE CREEK DR
Provider Second Line Business Practice Location Address:
STE. 150
Provider Business Practice Location Address City Name:
CHANHASSEN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55317-4610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-937-2839
Provider Business Practice Location Address Fax Number:
952-401-3307
Provider Enumeration Date:
04/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
AXEL-WEYANDT
Authorized Official First Name:
TIFFANY
Authorized Official Middle Name:
MAJA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
952-937-2839

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D11335 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com